Incidence of advanced intravenous access in 2 urban EDs.

BACKGROUND: In an emergency department (ED), intravenous (IV) access is frequently accomplished by inspection and palpation of peripheral veins. Failure of these methods indicates severe IV access difficulty and necessitates advanced techniques. Here, we estimate the incidence of advanced IV access in 2 urban EDs with varying resident coverage. METHODS: In this multiple-cohort study, we enrolled data from 2 neighboring urban EDs-a tertiary care ED and a community hospital affiliate. The 2 have similar volumes but the tertiary care ED has more resident coverage (112 vs 20 hours/d). In a prospective data collection (April 2012-2013), we enrolled consecutive patients during hours of scheduled shifts for research assistants. In a retrospective data collection (March 2011-2012), we reviewed charts of a random sample of patients from each ED for similar outcomes. We calculated the incidence of advanced IV access by dividing the number requiring advanced techniques by the number requiring IV access. RESULTS: We determined IV outcomes for 790 patients in the prospective cohort and 669 patients in the retrospective cohort. Between groups, there was no difference in the incidence of advanced IV access in the prospective collection (P = .08) or in the retrospective collection (P = .7). Pooling data from both cohorts and both hospitals, the overall incidence was 3.2 [95% confidence interval, 1.9-5.2] per 100 attempts. CONCLUSION: Advanced IV access is needed in 3.2% of IV attempts in 2 urban EDs with varying levels of resident coverage. We found similar incidence in both EDs.

Effect of length of progesterone exposure during ovulatory wave development on pregnancy rate.

The objective was to determine the effects of the duration of progesterone exposure during the ovulatory wave on fertility (pregnancy rate) in beef cattle. We tested the hypothesis that short-progesterone exposure during the growing and early-static phase of the ovulatory follicle (analogous to the ovulatory wave of 3-wave cycles) is associated with higher fertility than a longer duration of exposure (analogous to the ovulatory wave of 2-wave cycles). Three to 5 days after ovulation, beef heifers (n = 172) and suckled beef cows (n = 193) were given an intravaginal progesterone-releasing device (CIDR) and 2.5 mg estradiol - 17ß +50 mg progesterone im to induce a new follicular wave. Cattle were allocated to short- or long-progesterone exposure groups (for 3 and 6 d after wave emergence, respectively) after which prostaglandin F(2α) was administered and CIDR were removed. Forty-eight hours later, all cattle were given 12.5 mg pLH and artificially inseminated (AI) with frozen-thawed semen. The diameter of the two largest follicles and the corpus luteum were measured by transrectal ultrasonography at CIDR removal, insemination, and 36 h after insemination. Pregnancy diagnosis was done ultrasonically 38 and 65 d post-AI. There was no difference in pregnancy rates in short- vs long-progesterone exposure in heifers (53 vs 47%, P = 0.44) or cows (63 vs 58%, P = 0.51). However, the diameter of the ovulatory follicle at CIDR removal and AI was smaller in short- than in long-progesterone groups (P < 0.02), and larger in cows than in heifers (P < 0.006). In conclusion, short-progesterone exposure during the growing and early-static phase of the ovulatory follicle (similar to 3-wave cycles) was not associated with higher fertility than a longer progesterone exposure (similar to 2-wave cycles).

Ovulation, pregnancy rate and early embryonic development in vernal transitional mares treated with equine- or porcine-FSH.

The objective of this study was to compare the efficacy of purified equine- and porcine-FSH treatment regimes in mares in early vernal transition. Mares (n = 22) kept under ambient light were examined ultrasonographically per-rectum, starting January 30th. They were assigned to one of two treatment groups using a sequential alternating treatment design when a follicle >or= 25 mm was detected. In the eFSH group, mares were treated twice daily with equine-FSH, and in the pFSH group mares were treated twice daily with porcine-FSH; treatments were continued until follicle(s) >or= 35 mm, and 24 h later hCG was administered. Oestrous mares were inseminated with fresh semen and examined for pregnancy on days 11-20 post-ovulation. In the eFSH group, 11/11 (100%) mares developed follicle(s) >or= 35 mm, 8/11 (73%) ovulated and 6/8 (75%) conceived. In the pFSH group, 5/11 (45%) developed follicle(s) >or= 35 mm, 4/11 (36%) ovulated and 3/4 (75%) conceived. Treatment with eFSH resulted in a greater ovarian stimulation; higher number of pre-ovulatory-sized follicles, higher number of ovulations and higher number of embryos (p < 0.05). Following ovulation, serum progesterone concentrations were correlated with the number of CLs and supported early embryonic development; maternal recognition of pregnancy occurred in all pregnant mares. We concluded that eFSH can be used to effectively induce follicular growth and ovulation in vernal transitional mares; however, if bred, diagnosis and management of twins' pregnancies would be required prior to day 16 because of the increased risk of multiple embryos per pregnancy. Conversely, the current pFSH treatment regime cannot be recommended.

[CT examinations in children]. / CT-Untersuchungen bei Kindern.

Computed tomography (CT) accounts for a significant proportion of radiation exposure patients are exposed to during diagnosis, which means that particularly strict indications need to be observed especially where children are concerned. Numerous factors influence the level of radiation exposure, only a few of which can be changed by the radiologist and radiographer. Sound knowledge of the links between technical implementation and the resultant image quality needed for the diagnosis can dramatically reduce the radiation patients are exposed to, which in turn has an influence on the indications. In the present paper the radiologist is given tools for optimisation of CT examinations in children and accepted indications for CT of all body regions are presented.

[Diagnostic imaging in child abuse]. / Bildgebende Diagnostik der Kindesmisshandlung.

Diagnostic imaging in child abuse plays an important role and includes the depiction of skeletal injuries, soft tissue lesions, visceral injuries in "battered child syndrome" and brain injuries in "shaken baby syndrome". The use of appropriate imaging modalities allows specific fractures to be detected, skeletal lesions to be dated and the underlying mechanism of the lesion to be described. The imaging results must be taken into account when assessing the clinical history, clinical findings and differential diagnoses. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations must be performed in order to detect lesions of the central nervous system (CNS) immediately. CT is necessary in the initial diagnosis to delineate oedema and haemorrhages. Early detection of brain injuries in children with severe neurological symptoms can prevent serious late sequelae. MRI is performed in follow-up investigations and is used to describe residual lesions, including parenchymal findings.

[Congenital cystic lung malformations]. / Konnatale zystische Lungenfehlbildungen.

PURPOSE: The aim of the study concerning congenital cystic lung malformations was to evaluate prenatal diagnoses postnatally to determine prognostic factors as well as to define optimized perinatal management. MATERIALS AND METHODS: The study is based on 45 prenatal ultrasound examinations depicting fetal cystic lung lesions. 32 of the mothers had follow-up examinations. 5 pregnancies were terminated due to CCAM and additional malformations. Complete regression of the lesions was seen prenatally in 8 cases and postnatally in 5 children. RESULTS: Surgical intervention due to respiratory insufficiency was necessary in 4 neonates. According to the imaging results, CCAM was present in 4 cases and sequestration in 7 patients. No correlation between the imaging findings and the surgical results was found in 3 children: One child suffered from rhadomyoid dysplasia, and in the case of the second child, a left-sided hernia of the diaphragm and additional sequestration were detected. The third child showed AV malformation. The cystic lesions of the 14 children operated upon were proven histologically. The degree of accuracy in the present study was high. CONCLUSION: Precise perinatal management is warranted in order to determine according to the clinical relevance surgical intervention and to prevent complications after the first year of life. This is performed during the neonatal period for respiratory insufficient neonates and within the first year of life for clinically stable children.

Christmas surprise: the unnoticed journey of a needle-from bronchus to intestine.

We report on a 14-year-old Arabian girl who suddenly developed coughing after having aspirated a needle used for fixing her headscarf. The chest X-ray showed the needle located in the right main bronchus. However, subsequent flexible bronchoscopy could not detect any foreign body. A further X-ray of the abdomen showed the needle now behind the diaphragm. Gastro-oesophageal endoscopy was also uneventful. On the third day, the needle was excreted naturally. Astonishingly, this journey of the wandering needle from bronchus to intestine was not realised by the patient at any time. Our case highlights that children and adolescents should be warned repeatedly about the risks of putting needles between their teeth. It also reminds the physician to diagnose aspirated foreign bodies as early as possible to prevent wandering and migrating, which may induce new risks and unnecessary diagnostic and therapeutic procedures.

FDG-PET in 10 children with non-Hodgkin's lymphoma: initial experience in staging and follow-up.

BACKGROUND: The use of FDG-PET was evaluated for initial staging and therapy efficacy in paediatric patients with non-Hodgkin's lymphoma (NHL) and compared to the established conventional imaging modalities (CIM). The results of this retrospective analysis are presented in conjunction with a critical review of the current literature. PATIENTS AND METHODS: Ten paediatric patients with NHL were examined using whole-body FDG-PET initially (n = 6), during therapy (n = 5) and after completion of therapy (n = 5), respectively. FDG-PET findings were compared to CIM performed according to the protocol of the German NHL-BFM 95 study. The results were evaluated for their impact on disease classification and therapy decision (St. Jude, REAL) in correspondence to a clinical follow-up of at least 24 months. RESULTS: Concerning initial staging, all lymphoma manifestations detected by conventional imaging were also detected by FDG-PET (15 nodal, 2 extranodal). Furthermore, an additional nodal lesion was detected by FDG-PET in three patients. This resulted in an upstaging followed by an intensified poly-chemotherapy in one patient. In five patients showing unclear residual masses on conventional imaging during therapy, FDG-PET indicated viable residual tumours in one case. This patient showed a relapse during follow-up while the four FDG-PET negative patients did not. After completion of initial therapy, FDG-PET revealed in one out of five patients persistent tumour metabolism in the primary lesions and also detected new manifestations. The patient died shortly after restaging due to disease progression. CONCLUSIONS: These first results on the use of FDG-PET in paediatric non-Hodgkin lymphoma indicate a high potential to improve the therapeutic management.

[The clinical relevance of subcutaneous-thoracic ratio in preterm newborns as a possibility for quantification of capillary leak syndrome]. / Die klinische Bedeutung der Weichteildicke in Röntgen-Thoraxaufnahmen bei Frühgeborenen mit einem Geburtsgewicht unter 1500 Gramm - eine Quantifizierungsmöglichkeit des Kapillarlecksyndroms.

BACKGROUND: Capillary leak syndrome (CLS) is associated with increased morbidity and mortality in preterm newborns (PN) with sepsis or necrotizing enterocolitis. PATIENTS AND METHODS: In order to provide improved standards for measuring edema and for the definition of CLS, subcutaneous-thoracic ratios (S/T) were calculated from 821 anteroposterior supine chest radiographs of 119 PN with a birth weight below 1500 g. The S/T was computed by 100 % minus ratio of dividing the outer margins of the eighth rib by the total diameter of the thorax at the same position. Birth weight, gestational age, need for assisted ventilation and the position of the diaphragm did not significantly affect S/T. The S/T drifted downwards slightly with postnatal age. RESULTS: To provide normal standards of S/T in PN, the ratio was calculated in percentiles and the higher percentiles correlated with diseases. 771 S/T were lower than 10.1 % (95th percentile), 21 were 10.1 - 12.6 % (97.5th percentile) and 20 were even higher. 3 of the 100 PN (84 %) with an S/T < 10.1 % died because of extreme immaturity. Eight patients (6.7 %) had an S/T between the 95th and the 97.5th percentile in at least one of their radiographs. Four of them had a respiratory distress syndrome and one died. Eleven PN had an S/T > 12.6 %. All of them showed a multiple organ failure and four died. When the SIT was > 15 % the edema became visible. A CLS was diagnosed in two PN with an S/T > 20 %. CONCLUSIONS: The threshold for the capillary leak syndrome was found to be 12.6 % also in reference to the course of diseases. The S/T is a useful tool because it is simple to measure and calculate, and is available from a single frontal film. The ratio can measure objectively the edema and the CLS in PN.

[Prenatal diagnosis of obstructive uropathies - positive predictive value and effect on postnatal therapy]. / Pränatalsonographische Befunde bei obstruktiven Uropathien - positive Vorhersagefähigkeit und Bedeutung für die postnatale Therapie.

INTRODUCTION: Prenatal diagnosis of urological anomalies is a standard procedure nowadays. The aim of this study was first to define the frequency of urinary tract anomalies in the selected patients in a level III center for prenatal diagnostics and therapy. The second aim was to show the accuracy of prenatal diagnosis in the special groups of obstructive uropathies. PATIENTS AND METHODS: Postnatal diagnoses were used for control of the prenatal findings. In the 12-year retrospective study, we analyzed 21 616 pregnancies scanned for fetal anomalies. In 1 574 fetuses pediatric surgical anomalies were diagnosed. Out of 1 077 follow-ups 618 patients with urinary tract anomalies were found. RESULTS: It could be shown that prenatal ultrasound has a high sensitivity for the diagnosis of obstructive renal tract anomalies. The diagnosis of subpelvine obstruction and muticystic kidney dysplasia can be made with an accuracy of 97 and 98 %. The therapeutic relevance of the diagnosis "isolated hydronephrosis" increases up to 60 % when mild dilatation is neglected. False negative scans for urinary tract anomalies are low at 10 %. CONCLUSION: Hence, prenatal ultrasound for urinary tract anomalies is a method of high sensitivity. The therapeutic relevance is rather high. The most important question is to find all those patients who need a postnatal therapeutic approach immediately.

Follow-up of unilateral multicystic kidney dysplasia after prenatal diagnosis.

OBJECTIVES: Since the introduction of antenatal diagnostic screening, multicystic kidney dysplasia (MCKD) has been diagnosed in 1 of 4300 live births. We analyze our own experience and demonstrate a management regime based on these results and existing studies. METHODS: Retrospective data analysis was carried out in 110 patients, prenatally diagnosed with MCDK. A total of 93 patients with confirmed diagnosis of unilateral MCDK were born alive and followed up in our institutions. RESULTS: A total of 110 unilateral cystic kidneys were prenatally diagnosed; 93 were confirmed postnatally. These children were retrospectively allocated to two treatment groups: 51 were operated upon; 42 were treated conservatively. A micturition cystourethrogram was performed 88 times, yielding 20 pathological findings. Vesicoureteral reflux was identified 11 times (12.5%). Eleven children (12%) had associated non-urological abnormalities. Cardiac and musculoskeletal malformations predominated. After 1995, nephrectomy was performed only when clinically indicated. Thirty-seven children were treated conservatively for between 4 months and 6 years (mean 33 months); 28 dysplastic kidneys exhibited size reduction. Complete involution was noted in 16 of 28 children between 7 and 29 months (mean 16.2 months). CONCLUSION: This study provides evidence that neonatal nephrectomy of unilateral MCDK is rarely required. It also shows that the discussed malformation is not an isolated developmental abnormality. In a high proportion, associated urogenital abnormalities were present and therapeutically relevant, and determined the overall prognosis.

[Retrospective analysis of differential therapeutic measures in children with double kidney and ureter and hydronephrosis]. / Retrospektive Analyse des differentialtherapeutischen Vorgehens bei Kindern mit Doppelnieren mit Ureter duplex und Harntransportstörung.

In this study, we analyzed the findings of 79 duplex kidneys in 64 children treated at our institution between 1987 and 1999. Several reasons for impaired urine transport in a duplex kidney were clarified. A total of 55% of all patients manifested a variety of abnormal findings during prenatal screening. In the course of postnatal diagnostic work-up, renal units were classified according to their leading pathomorphological features: 44% showed a ureterocele, 29% nonfunctioning units at first diagnosis, and 27% vesicoureteric reflux. Nonfunctioning moieties had been heminephrectomized in most cases. In such nonfunctioning cases in the presence of associated ureteroceles, relief drainage was unsuccessful in our study. Reflux rarely matures. Ureterocystoneostomy is successful in 80% of our cases. In functioning units with a ureterocele, endoscopic therapy may be the one and only intervention needed. However, they commonly require secondary reconstructive measures.

[Rare mesenchymal lesions in siblings. Two case reports]. / Seltene mesenchymale Läsionen bei Geschwisterkindern. Zwei Fallberichte.

We report on a 15-month-old boy presenting a juvenile active ossifying fibroma in the right nasal cavity and the sibling, a 9-month-old girl with a mesenchymal hamartoma of the chest wall. The two lesions showed many similarities. Both lesions are present at the time of birth or in early life with local obstructive or compressive effects. The lesions have a similar mixture of mature and immature mesenchymal tissue with areas of ossification. The entities present a tumor-like development with an abnormal mixture of tissue indigenous to the specific area of the body without notable atypical cytologic features. These features are typical criteria for hamartoma lesions.

Prevalence of nosocomial infections in neonatal intensive care unit patients: Results from the first national point-prevalence survey.

OBJECTIVES: Patients admitted to neonatal intensive care units (NICUs) are at high risk of nosocomial infection. We conducted a national multicenter assessment of nosocomial infections in NICUs to determine the prevalence of infections, describe associated risk factors, and help focus prevention efforts. STUDY DESIGN: We conducted a point prevalence survey of nosocomial infections in 29 Pediatric Prevention Network NICUs. Patients present on the survey date were included. Data were collected on underlying diagnoses, therapeutic interventions/treatments, infections, and outcomes. RESULTS: Of the 827 patients surveyed, 94 (11.4%) had 116 NICU-acquired infections: bloodstream (52.6%), lower respiratory tract (12.9%), ear-nose-throat (8.6%), or urinary tract infections (8.6%). Infants with infections were of significantly lower birth weight (median 1006 g [range 441 to 4460 g] vs 1589 g [range 326 to 5480 g]; P <.001) and had longer median durations of stay than those without infections (88 days [range 8 to 279 days] vs 32 days [range 1 to 483 days]; P <.001). Most common pathogens were coagulase-negative staphylococci and enterococci. Patients with central intravascular catheters (relative risk = 3.81, CI 2.32-6.25; P <.001) or receiving total parenteral nutrition (relative risk = 5.72, CI 3.45-9.49; P <.001) were at greater risk of bloodstream infection. CONCLUSIONS: This study documents the high prevalence of nosocomial infections in patients in NICUs and the urgent need for more effective prevention interventions.

Neonate with spinal hypoplasia on T12 and a localized vertebral malformation on L4.

We report a case of a neonate with sectional narrowing of the spinal cord on the level of T12 to L2 and a deformed vertebral body on a different level, L4. In previously described cases of sectional spinal dysgenesis, the vertebral and spinal cord malformations are usually found on the same level. Our case may represent a new variant of spinal dysgenesis.

Nosocomial infection rates in US children's hospitals' neonatal and pediatric intensive care units.

BACKGROUND: Few data are available on nosocomial infections (NIs) in US children's hospitals' neonatal or pediatric intensive care units. The Pediatric Prevention Network (PPN) was established to improve characterization of NIs in pediatric patients and to develop and test interventions to decrease NI. METHODS: Fifty participating children's hospitals were surveyed in 1998 to determine NI surveillance methods used and neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) 1997 NI rates. Data were collected on standardized forms and entered and analyzed by using SPSS for Windows. RESULTS: Forty-three (86%) children's hospitals returned a completed questionnaire. All reported conducting NICU and PICU NI surveillance (range, 2-12; median, 12 months). Nineteen children's hospitals provided NICU NI rate data in one or more formats suitable for comparison. Denominators used for NICU NI rate calculations varied: 17 reported overall NI by patient-days; 19 reported bloodstream infection (BSI) by central venous catheter (CVC)-days, and 8 reported BSI by patient-days. Sixteen (16) children's hospitals reported NICU BSI data stratified by CVC-days and birth-weight cohort, and ventilator-associated pneumonia (VAP) by birth weight cohort was reported by 12. Twenty-four children's hospitals reported PICU NI rate data in one or more formats suitable for comparison. Denominators used for PICU NI rate calculations also varied: 20 reported overall NI rates by patient-days; 23 reported BSI rates by CVC-days, and 10 reported BSI rates by patient-days; 24 reported VAP by ventilator-days; and 15 reported urinary tract infections (UTIs) by urinary catheter-days. Median overall NI rates per 1000 patient days were 8.9 in NICUs and 13.9 in PICUs. Median NICU NI device-associated rates by birth weight (>2500 g, 1501-2500 g, 1001-1500 g, and

Colonic pneumatosis intestinalis in preterm infants: different to necrotising enterocolitis with a more benign course?

UNLABELLED: Necrotising enterocolitis (NEC) is the predominant immaturity-associated disease of the bowel in the preterm neonate and leads to substantial mortality and long-term morbidity. Diagnostic features of NEC include, apart from the clinical presentation, laboratory and radiological parameters. Pneumatosis intestinalis (PI) on abdominal radiographs is regarded as a criterion of definitive proof for this disease entity. The objective of this presentation is to link the topographic pattern of PI to the clinical course in cases of suspected NEC. We report two cases of radiological appearance of colonic PI indicative of NEC without associated laboratory and/or macroscopic evidence of the disease, and with minor clinical symptoms only. Data from animal studies indicate that decreased blood supply to the small bowel is associated with more extensive bowel damage as compared to impaired colonic perfusion. Therefore the topographical distribution of PI might be a more specific sign as the general presence or absence of PI. CONCLUSION: The topographical pattern of pneumatosis intestinalis may be predictive of the clinical course of inflammatory bowel disease in preterm infants.

[Abdominal magnetic resonance tomography in the child]. / Abdominelle Magnetresonanztomographie beim Kind.

MRI provides diagnostic information in multiple abdominal diseases in childhood. Additional information to sonographic findings can be achieved in the diagnosis of abdominal malformation as well as in several inflammatory processes. In childhood cancer imaging MRI is essential at the beginning as well as during therapy to assess response to therapy. Because of radiation protection MRI has to replace CT in abdominal imaging in children. Some technical details have to be considered when children are examined.